Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Comorbid Conditions

Factors Influencing Duration

The degree of bone displacement, the presence or absence of damage to adjacent blood vessels or nerves (brachial plexus), whether reduction was closed or open, whether the dominant or nondominant side is involved, and the individual's job requirements all affect the duration. Work duties that can be performed with one hand or arm may allow for a shorter duration.

Medical Codes

ICD-9-CM:

810.00 -

Closed Fracture, Clavicle, Unspecified Part

810.01 -

Closed Fracture, Clavicle, Sternal End of Clavicle

810.02 -

Closed Fracture, Clavicle, Shaft of Clavicle

810.03 -

Closed Fracture, Clavicle, Acromial End of Clavicle

810.10 -

Open Fracture, Clavicle, Unspecified Part

810.11 -

Open Fracture, Clavicle, Sternal End of Clavicle

810.12 -

Open Fracture, Clavicle, Shaft of Clavicle

810.13 -

Open Fracture, Clavicle, Acromial End of Clavicle

Overview

&COPY; Reed Group

Fracture of the collarbone (clavicle) can occur when force or stress is applied to the shoulder or upper chest.

The clavicle is an oval, slightly "S"-shaped bone that is located the top of the chest linking the breastbone (sternum) to the shoulder. One end attaches to the sternum, and the other attaches to the acromion, which is part of the shoulder blade (scapula). The clavicle supports the arm, transmitting forces from the arm to the central skeleton. The ligaments connecting the clavicle to the sternum and scapula are very strong. Therefore, the joints on either end of the clavicle rarely dislocate but force will fracture the clavicle.

Because of its "S" shape, the clavicle is vulnerable to fracture, especially near the curves. Fractures are classified by their position along the bone and also by the amount of separation (displacement) between the bone fragments. Most fractures of the clavicle are uncomplicated. Uncomplicated implies no damage to nerves (brachial plexus), blood vessels (subclavian artery and vein, internal jugular vein, axillary artery) or the lungs. Because the clavicle provides suspension of the shoulder to the trunk, an injury to the clavicle can be thought of as an injury to the entire shoulder area.

Incidence and Prevalence: The clavicle is one of the most frequently broken bones and accounts for 4% to 10% of all adult fractures and 35% to 45% of all fractures that occur in the shoulder girdle. Fracture of the middle third segment (grade 1 fracture) accounts for 72% to 80% of all clavicle fractures, and those of the lateral third (grade 2 fracture) or medial third (grade 3 fracture) account for 25% to 30% and 2%, respectively (Kleinhenz).

Causation and Known Risk Factors

Individuals at risk for a clavicle fracture are those who participate in contact sports such as football, wrestling, softball, baseball, and boxing. Individuals involved in a motor vehicle collision are also at risk. Twice as many clavicle fractures occur in men as women. At the mean age of 21 years most clavicle fractures are due to sports-related injuries; at the mean age of 46 years falls onto the shoulder are the primary mechanism of injury (Cheung). A fall onto an outstretched arm/hand but not the shoulder may also rarely result in a clavicle fracture.

The clavicle, particularly its medial region, is a possible site of pathologic fracture with minor trauma.

Diagnosis

History: A complete medical history should include the circumstances surrounding the injury, any underlying medical conditions, current medications, allergies, and occupation. The individual usually reports a recent accident or injury such a fall or blow. Symptoms include pain and local swelling. The affected arm may feel numb and be immobile. The individual reports a grinding sensation with attempts to move the arm. The affected shoulder may droop or fall forward. Pain may be referred across the upper shoulder and neck.

Physical exam: Physical examination begins with observation of the injured area. There may be an obvious deformity, swelling, and bruising (ecchymosis). The injured area should be inspected carefully for abrasions or wounds that may indicate an open fracture. The affected shoulder may slope downward and forward from loss of support. The location of the fracture may be detected by touch (palpation). The range of motion in the affected shoulder and strength in the surrounding muscles may be impaired. Because major blood vessels (subclavian artery and vein, internal jugular vein, axillary artery) and nerves (brachial plexus) are located near the clavicle, a thorough neurovascular evaluation is routine. Listening to the lungs with a stethoscope (auscultation) can reveal changes in breath sounds associated with a lung collapse (pneumothorax).

Tests: Plain x-rays of the clavicle or upper chest usually are adequate to determine the location and severity of the fracture unless there is a concern regarding vascular or neurological injury. In the case of severe trauma, a chest film and other imaging studies (computed tomography [CT], magnetic resonance imaging [MRI]) may also be required to detect any associated injuries. Rarely is electromyography (EMG), which measures the electrical activity of muscles, required in the early diagnostic phase. If injury to a major blood vessel is suspected, angiography or venography may be done to assess the damage.

Treatment

The location of the fracture determines the optimal treatment. Some clavicle fractures can be treated effectively with conservative measures such as immobilization in a sling or a sling and swathe (a bandage that reduces movement by binding the arm close to the body) for 4 to 6 weeks. A figure 8 harness was commonly used but studies suggest it is not effective and since the straps wrap around the arms and can cause skin irritation and breakdown, it is less commonly used today. If the ends of the broken bone have become separated or are in an abnormal position (displaced fracture), the bones need to be restored to their normal position (reduction). Gradual reduction over time with the sling may occur. Attempts of closed reduction are unlikely to remain aligned and therefore are falling out of favor. The reduction does not have to be exact for healing to occur.

Displaced fractures that are difficult to reposition by closed methods may require surgical intervention (open reduction and internal fixation [ORIF] with pins, screws, and/or plates. Previously, displaced fractures of the distal clavicle (near the shoulder) were the type most likely to be treated operatively, but increasing numbers of displaced fractures of the mid-shaft clavicle are being treated surgically with plate fixation. Results show improved functional outcomes and a lower rate of fracture nonunion or malunion compared with the previous non-operative treatments (Pujalte).

An open fracture (one in which the bone protrudes through the skin) requires surgical consultation. Other indications for surgery include damage to surrounding blood vessels and nerves.

Fractures near the sternum are treated with comfort measures, such as a sling for support; this type of fracture is fairly uncommon. Treatment for all types of fracture usually includes cold therapy (ice), analgesics, and education in proper posture. Electromagnetic current or ultrasonic pulse therapy may be utilized to treat fractures that are not healing (nonunion), but these therapies are not as effective as bone grafting and internal fixation.

Prognosis

Whether treated conservatively or by open reduction, most clavicle fractures have a good outcome. Most fractures heal within 6 to 8 weeks without complications or residual disability. Nonsurgical treatment often results in a cosmetic deformity (bone bump). Fractures in the distal one-third of the clavicle have a higher risk of not healing (nonunion). Nonunion is rare, unless ORIF fails. Fractures that involve the shoulder (acromioclavicular) joint have a risk of developing degenerative arthritis.

Rehabilitation

The duration and type of rehabilitation for a clavicle fracture is related to the extent of soft tissue and neurovascular involvement and the location and type of fracture. Protocols for rehabilitation must be based upon stability of the fracture and fracture management (operative, nonoperative). Hand dominance and the involved extremity will greatly influence the individual's degree of disability. After the fracture is healed, if shoulder limitations are present, rehabilitation should emphasize restoring full range of motion and strength of the shoulder while maintaining independence in all activities of daily living (Bucholz). Resumption of pre-injury status is the goal with consideration of any residual deficit.

The goal of rehabilitation is to decrease pain and restore function of the affected shoulder girdle. Local cold application may be beneficial for controlling pain and edema (Salter). During immobilization, rehabilitation should focus on full function of the adjacent joints, based on the stability of the fracture (Koval). When indicated, shoulder exercises on the involved side can be introduced, in order to regain full range of motion and strength (Bucholz). Exercise intensity and difficulty should be progressed until full function is achieved. Rehabilitation must emphasize functional use of the involved extremity.

In addition to undergoing supervised rehabilitation, the individual should be instructed in a home exercise program to be practiced daily and continued independently after the completion of rehabilitation. Occupational therapy may be indicated to assist with activities of daily living if necessary.

If operatively managed, protocol of rehabilitation will be dictated by the treating physician.

Bone healing may occur within 6 to 12 weeks; however the bone strength and the ability of the bone to sustain a heavy load may take up to several years (Chapman). Once healing has occurred, the individual may resume full activities of daily living. It is important to instruct the individual not to overload the fracture site until the bone has regained its full strength. The resumption of heavy work and sports should be guided by the treating physician.

FREQUENCY OF REHABILITATION VISITS

Nonsurgical

Specialist

Fracture, Clavicle

Physical or Occupational Therapist

Up to 4 visits within 8 weeks

Surgical

Specialist

Fracture, Clavicle

Physical or Occupational Therapist

Up to 12 visits within 12 weeks

The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice.

Complications

In a clavicle fracture, damage can also occur to the underlying nerves (brachial plexus) and blood vessels (subclavian artery and vein, internal jugular vein, axillary artery) or to the ligaments around the acromioclavicular joint. Incorrect fusion (malunion) or failure of the bone ends to fuse together (nonunion) can result from inadequate reduction or the failure to maintain reduction of a displaced fracture. Malunion can cause a bony deformity that may be cosmetically unacceptable. In some cases, the malunion can compress adjacent blood vessels or nerves resulting in thoracic outlet syndrome. Nonunion occurs in 13% of displaced clavicle fractures treated nonoperatively (Murray).

Ability to Work (Return to Work Considerations)

Work guides may include no lifting, carrying, pushing, pulling, or overhead work until the fracture has healed. The individual with a clavicle fracture on the dominant side may be temporarily unable to write legibly, type well, or perform activities that require fine motor skills, such as those needed to work in a laboratory or on an assembly line. The individual may also be temporarily unable to operate heavy equipment, as well as a car or other motor vehicle. The union may not be strong enough for 16 to 24 weeks to allow lifting heavy weights above the shoulder. Ice packs and rest periods may be necessary to control swelling and numbness of the arm during the first 1 to 2 weeks. The use of elevated tables for work performed while standing, or duties that require the use of one hand only, may allow an earlier return to work. Site visits by an occupational therapist may identify other workstation accommodations.

Risk: Risk is dependent on the diagnosis and mechanism of injury that caused the fracture.

Capacity: Capacity will vary depending on diagnosis, mechanism of injury, and the associated soft tissue, vascular, and nerve injuries.

Tolerance: Tolerance for fracture pain is a frequent reason individuals choose to participate in or avoid specific activities, considering the rewards (salary, enjoyment) versus the cost (pain). Tolerance will also be impacted by a capacity greater than the risk.

Accommodations: Accommodations are the key to one's ability to return to activities.

Maximum Medical Improvement

Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

Did individual experience a direct blow to the shoulder, a fall onto the shoulder, or a fall onto the outstretched arm/hand?

Does individual report pain and local swelling? Was obvious deformity, swelling, and bruising present?

Does affected arm feel numb or have a sensation of burning or prickling (paresthesia)?

Is the arm immobile?

Does affected shoulder droop or fall forward?

Does holding the injured shoulder in a guarded, rigid position cause muscle spasm and additional pain across the upper shoulder and neck?

Were breath sounds normal?

Were plain x-rays of the clavicle or chest obtained?

Was electromyography (EMG) necessary to rule out nerve damage? Was angiography or venography performed?

Regarding treatment:

Was conservative treatment, through the use of immobilization in a sling or a sling and swathe, or with a figure 8 harness, for 4 to 6 weeks, sufficient to resolve the fracture?

Were broken ends of the bone separated or in an abnormal position (displaced fracture)?

Were they restored to their normal position without surgery (closed reduction)?

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